Hebrew Rehabilitation Center in Boston is a licensed chronic care hospital and a leading provider of geriatric health care services in the area. The facility has shown that an intervention including AHRQ's Project Re-Engineered Discharge (Project RED) can significantly decrease hospital readmissions.

Randi E. Berkowitz, MD, Medical Director for Subacute Care at Hebrew Rehabilitation Center, has long been interested in reducing rehospitalizations of patients who are admitted from skilled nursing facilities. Berkowitz incorporated elements of Project RED into a demonstration project at the Center's Boston campus in August 2010. Berkowitz says, "We designed the intervention at the Boston campus to promote the importance of patient care goals and to help staff see care transitions as an important part of their work."

Nursing staff use Project RED as an educational tool to help patients learn about various aspects of their hospitalization, such as the nature of their illness and their medications. Upon discharge, the patient is given a care plan modeled after Project RED's "After Hospital Care Plan."

As of February 2012, the rate of readmission for patients who were part of the Project RED intervention was 11.4 percent compared with 17.4 percent for patients who were not part of the program.

Additionally, 90 percent of admitted patients received the full intervention. Of these patients, nearly 93 percent understood their medications compared with 60 percent of patients who were not part of the program, and 54 percent of patients learned about side effects for new medications compared with approximately 17 percent of patients in the nonintervention group.

With about 1,000 admissions annually, the Boston hospital has 405 long-term care hospital beds, 46 post-acute beds in the medical acute care unit, and 50 short-term, skilled nursing beds in the recuperative services unit. The latter unit provides rehabilitation services, including physical therapy, occupational therapy, and speech therapy for patients after an acute hospital stay and before returning to their home in the community.

The program to reduce rehospitalizations implemented by Berkowitz included the following:

Advanced care planning to help patients and their caregivers determine the best treatment plans, including palliative care consultations for high-risk patients.

Multidisciplinary Team Improvement for the Patient and Safety conferences, where staff analyzed the root causes of avoidable readmissions and near misses in a blame-free environment, encouraging open discussion about what steps can be taken to improve patient outcomes.

Patricia O'Brien, RN, is the Executive Director of Hebrew SeniorLife Home Care. Her staff provides in-depth monitoring of home-care patients to detect health-related problems before they turn into acute episodes that require hospitalization. The rate of patients who saw their primary care provider within 30 days after leaving Hebrew's skilled nursing unit improved from 46 to 70 percent after implementing Project RED. Discharged patients are surveyed by telephone 30 days after leaving the skilled nursing unit.

O'Brien says about Project RED, "Once patients are back home, home health care providers reinforce the Project RED program and become the eyes and ears for physicians."